Last Name First Name MI LSU ID# Social Security# (US residents only) REQUIREMENT Records Office Unspecified Student Registration Form Term (Please check one): o Summer o Fall o Winter o Spring Course Information (PLEASE PRINT CLEARLY) Prefix Course # Section # Course Title YEAR: _____________________ Units Audit? Instructor Signature *if class is full o o o o Demographic Information PERSONAL INFORMATION Date of Birth Sex Ethnicity State/Country of Birth Citizenship o M o F Social Security Number Religious Affiliation o US Highest diploma or degree earned: o Other: Type of Visa _________________ o High School o Masters CONTACT INFORMATION Home Address (Street & Apt. Number) City Telephone E-mail Address o Associate o Specialist State o Bachelor o Doctorate ZIP Payment of fees is due at the time of registration; financial aid or financial arrangements are not available. For information on tuition fees for Fall, Winter, and Spring, please visit www.lasierra.edu/sfs and click TUITION AND COSTS For information on tuition fees for Summer, please visit www.lasierra.edu/summer and click TUITION AND FEES CREDIT CARD INFORMATION Credit Card Type: Name on Card: o Visa o Master Card o Discover o American Express Credit Card #: Expiration Date: Three Digit Security Code: By Signing, I authorize La sierra University to charge the full tuition and fee amount to the card listed on this form. Cardholder’s Signature: Policies: Please initial each line indicating that you are aware and understand each policy. 1. _____Financial aid is NOT available to unspecified students. 2. _____Payment of Tuition and fees is to be paid in FULL at the time of registration to the credit card provided on this form. 3. _____Return this completed form to the Records Office, in person or via email, fax, or mail in order to complete registration. 4. _____Unspecified non-degree status is reflected on the student’s transcript. Please select one of the following: o I do not release any information to any 3rd parties. OR o I release information to ____________________________________ ,___________________________ Last I agree to the above and applicable policies and verify that the information provided is correct. First ____________________________________________________________________________ Student Signature Date 4500 Riverwalk Parkway. Riverside, CA 92515 ¡ (951) 785-2006 ¡ (951) 785-2447 FAX ¡ [email protected]